EMS Triage and Transport Guidelines

System Background

Minnesota’s statewide trauma system was established in July 2005 when Gov. Pawlenty signed legislation into law charging the Commissioner of Health to adopt criteria ensuring that severely injured people are promptly transported and treated at trauma hospitals appropriate to the severity of their injuries. In conjunction with the enactment of the trauma system law, the Emergency Medical Services Regulatory Board was successful in initiating complementary legislation to ensure the ambulance services are prepared to participate in a statewide trauma system.

EMS Requirements

With the implementation the of the new statewide trauma system, licensed ambulance services will be required to have written, age-appropriate triage and transport guidelines consistent with the criteria issued by the State Trauma Advisory Council (STAC) and approved by the Emergency Medical Services Regulatory Board (EMSRB). The EMSRB may approve an ambulance service’s requested deviations from the guidelines due to the availability of local or regional trauma resources if the changes are in the best interest of the patient's health. The EMSRB statute, Minn. Stat., sec. 144E.101, subd. 14, requires the guidelines to be established and approved by July 1, 2010

Trauma System Criteria

Minnesota Statutes, section 144.604 effective July 1, 2010 requires that ground ambulances transport major trauma patients with compromised airways immediately to the nearest designated trauma hospital if one exists within 30 minutes transport time. If no trauma hospital exists within 30 minutes, the patient with a compromised airway must be transported to the closest hospital. Additionally:

Ground ambulances must transport major trauma patients to a level I or II trauma hospital if one exists within 30 minutes transport time;

If no level I or II trauma hospital exists within 30 minutes, ground ambulances must transport to the closest trauma hospital, or to a more appropriate, higher–designated trauma hospital if predetermined by the ambulance service medical director;

If no designated trauma hospital exists within 30 minutes transport time, ground ambulances must transport to the closest hospital.

This “30 minute rule” means that an undesignated hospital will be bypassed for a designated trauma hospital that is within 30 minutes transport time.

Guidelines Development

Trauma hospitals vary in their resources and their capacity to care for certain injuries. Therefore, local trauma triage and transport guidelines should consider the specific injuries for which the local trauma hospitals are capable of caring, thus avoiding the unnecessary transfer of patients who can be treated locally or regionally. Developing and maintaining open communication with local hospitals while considering the patients’ best interest is imperative for developing an optimal trauma triage and transport guidelines.

The guidelines should also identify which patients will be transferred to another hospital emergently. In such cases the provider should notify the local receiving facility of the patient’s condition so that arrangements for transfer to definitive care can begin immediately.

The patient’s best interest may be served best by using air medical transportation or an advanced life support (ALS) ground ambulance intercept. These options may provide initial transport to definitive care or offer the patient a higher level of care without prolonging scene time. If air medical transport can arrive on scene within 15 minutes of EMS arrival, delaying transport for a helicopter scene response may be appropriate. Otherwise, the air medical provider should typically be instructed to meet the patient at the receiving hospital. As always, this decision will be made by the EMS responder.

It is expected that EMS providers and/or on-line medical control may override these guidelines when it is in the patient’s best interest. In such circumstances, the EMS medical director should review the case with the ambulance crew afterward to ensure it was appropriate and to determine if there is a need for education or policy review. Consultation with the STAC and the EMSRB Medical Direction Advisory Committee is always available to medical directors.

Special Considerations

The following injuries are typically cared for definitively at a level I or II trauma hospital:

Spinal cord injuries

Closed head injuries with a decreased LOC, penetrating head injuries or depressed skull fractures

Unstable or open pelvic fractures

Major chest wall injuries

Multiple long bone fractures

Multiple system injuries (e.g., head and chest, chest and abdomen)

Second or third degree burns over >20%TBSA are definitively cared for at a burn center.

Critical Trauma Patient Indicators

The following indicators identify trauma patients who meet the transport parameters of the state guidelines. The existence of any one or more of these indicators should trigger use of the service’s written trauma triage and transport guideline.

Altered level of consciousness (less than “A” on AVPU scale) resulting from a traumatic event

Respiratory distress or airway compromise resulting from a traumatic event

Shock or diminished perfusion resulting from a traumatic event

Severe burns

Other considerations:

Severe multiple injuries (2 or more systems) or severe single system injury

Cardiac or major vessel injuries resulting from a blunt or penetrating trauma

Steps to Developing Trauma Triage and Transport Guidelines

Determine the trauma designation level of the hospitals within 30 minutes transport time of the primary service area. Determine the distance to level I and II trauma centers from your service area.

Establish a line of communication with the hospitals within 30 minutes transport time and identify their capabilities with respect to trauma. (View designated hospitals in your area. Click on a hospital to view contact information.)

Develop triage and transport guidelines for major trauma in accordance with Statewide Trauma System criteria.

Develop and implement guidelines for activation of air medical and/or ALS intercept consistent with local resources.

Develop and implement a reporting and follow-up mechanism for guideline deviations.